She used other drugs for a different reason: her chronic pain. For many years, she had been able to find effective pain relief from a combination of long-acting fentanyl patches and biologic medicines.

But by the mid 2010s, the drug war had clamped down on opioid prescribing and fentanyl patches were no longer available to anyone. Doctors had begun requiring patients to sign “contracts,” promising not to drink alcohol or use other drugs, in order to get prescriptions for oral opioids.

Brenda had previously found oral opioids to be ineffective for her. She also said that she had an excellent relationship with her rheumatologist of 15 years. Despite this, she was required to sign such an agreement.

Brenda said she felt shame in being treated as a “drug seeker.” And she was now unable to manage her disabling pain. In the past, these had been factors that triggered her alcohol and benzodiazepine use.

Brenda came to terms with it, saying, “I have chronic pain and I have to take BioJesus.”

But she then agreed with her rheumatologist to investigate medical cannabis, which was legally available where she lived in Pennsylvania, as a pain-management option.

So Brenda visited her local dispensary numerous times, trying several different strains. And eventually, she found one particular strain that was effective in helping not only her pain, but her mood and anxiety. It was called “BioJesus.”

Although she had smoked cannabis in college, she still felt awkward talking to dispensary staff about “BioJesus.” She would have felt a lot more comfortable, she said, talking to a pharmacist about medication.

She’s not alone in those feelings. Older patients, particularly, have sometimes told me that they’re leery of trying cannabis because the “playful” strain names don’t reflect the seriousness of their search for an important medication. But Brenda came to terms with it, saying, “I have chronic pain and I have to take BioJesus.”

“The BioJesus worked remarkably well,” she told me, “but the availability was sporadic so I couldn’t be assured of having consistent relief, which compounded my problems.”

She found this incredibly frustrating. “Could you imagine if a diabetic person had an insulin supply issue? It would be catastrophic.”

What’s more, her aging mother was living with her at the time, and strongly disapproved of cannabis use. So Brenda had to hide it—and go outside to smoke.

It isn’t difficult to see multiple layers of cannabis stigma that impacted Brenda’s access and health. Stigma, often hidden in plain sight, has been the experience of many of my clients.

But she lived on the campus of a trade school, where her husband was a faculty member. This school had a “drug-free” policy. So she was left with the choice of either smoking it outside and potentially putting her husband in a difficult position, or walking much further away, which her pain made hard to do.

It isn’t difficult, in reviewing Brenda’s story, to see multiple layers of stigma around cannabis that impacted her access and health. And stigmatization of cannabis use continues to be pervasive in our culture.

That assertion may surprise some people. After all, close to half of Americans now live in states where cannabis is fully legal—and a large majority in states where there is at least some medical access. We overwhelmingly want cannabis to be legal, too.

Yet stigma, taking varied forms and often hidden in plain sight, has been the experience of many of my clients who use cannabis.

Working With Teens Who Use Cannabis

Much of my clinical work is with people far younger than Brenda, along with their families. I often find that youth and their parents have differing views about cannabis use, and I seek to help them all to disentangle myths from reality.

Young people have often discovered that cannabis can help them in ways that parents are likely unaware of. Teens who struggle with symptoms of bipolar disorder, PTSD, ADHD, anxiety or depression may have experimented with cannabis and found that it works to alleviate their symptoms, often without the side effects of psychiatric medications. Parents who were raised with the idea of cannabis as a “drug of abuse” may be deeply concerned.

A frequent example in my practice is when a teen client tells her parents that cannabis helps her sleep or reduces her anxiety. If her parents are overreacting, I may gently suggest that they reflect on their own substance use—whether it’s alcohol, prescribed sleep medications or anti-depressants, or even cannabis—and why they don’t feel alarmed about that.

I’ll often point out, too, that forbidding cannabis use hasn’t stopped their teen from accessing it—whereas teens tend to use substances more safely when they can be open and have their parents’ support.

At the same time, I’ll advise the teen that with any medicine, it’s best to consult with a health care professional trained in recommending and dosing that substance. Cannabis isn’t for everyone: There are obvious risks with medical cannabis for some people struggling to manage their emotions, and generally it’s best that adolescents avoid using cannabis until they are older.

Better knowledge about cannabis empowers people to make informed decisions about the roles it will or won’t play in their lives.

Drug-war propaganda about cannabis, and its continuing Schedule I status under federal law, are wildly inappropriate. Relatedly, the stigmatizing “replacing one drug with another” narrative, which dissuades people from using medical cannabis as a harm reduction alternative, is rooted in misinformation promoted by traditional treatment providers. And though people who use cannabis regularly are as active as anyone else, a persistent, harmful stereotype is that they’re unable to move from the couch.

However, all of us in this field have also encountered legalization advocates who promote cannabis as a completely “safe” drug without any potential harms for anyone. Cannabis has a low risk profile. But as with any drug, there are some potential harms, and denying this does nothing for anyone’s credibility. Cannabis use disorder does sometimes occur—even if this speaks less to the properties of cannabis than to the fact that people may experience addiction to activities of all kinds.

With clients, our conversations often touch on the endocannabinoid system (ECS)—one of the most important regulatory systems in our bodies, yet familiar to very few people outside the cannabis advocacy, harm reduction, or medical communities. It was discovered 35 years ago—astonishingly recent, when you consider that the ECS is vital for almost every aspect of our minute-to-minute functioning. It regulates and controls many of our most critical bodily functions such as inflammatory and immune responses, learning and memory, sleep, emotional processing, pain control, appetite and temperature control.

Our bodies naturally produce molecules called endocannabinoids, which are similar in structure to molecules in the cannabis plant. All of us have cannabis-like molecules floating around in our brains. The cannabis plant’s effects come through the unique way it connects with our bodies’ cellular mechanisms.

Educating my clients about the ECS can help reframe their perceptions of a medicine that can help with many conditions (though qualifying conditions vary by state). In general, better knowledge about cannabis empowers people to make informed decisions about the roles it will or won’t play in their lives.

It’s important to avoid one-size-fits-all platitudes such as “no one with bipolar disorder should ever use cannabis” or “cannabis makes ADHD worse.” There are always important caveats.

I also educate families about the role of the medical cannabis caregiver, which in many states gives a parent the legal ability to purchase cannabis for their child. This allows a parent and their teen to collaborate on what works best for them, thereby building trust and improving the relationship as well as the young person’s health.

Language matters, too. While there is a growing awareness of how the words  “alcoholic” and “addict” are stigmatizing, the equally stigmatizing terms “stoner” and “pothead” still seem to be more socially accepted. I sometimes find myself having to educate even my harm reduction colleagues about this.

Cannabis as medicine is not really about getting high. But when people do use cannabis for its euphoric effects—which might simultaneously improve their mood, anxiety or sleep—we should never be judgmental about it. People have wanted to alter their consciousness since people have existed.

Cannabis affects each person differently, so it’s important to avoid one-size-fits-all platitudes such as “no one with bipolar disorder should ever use cannabis” or “cannabis makes ADHD worse.” There are always important caveats to consider. But my clinical experience has taught me that it can be an effective harm reduction tool for many.

I collaborate with my clients to help them find balance in their lives. If they choose to use cannabis, I work to help them do so in a way that is healthier and contributes to their overall life goals.

Parents’ Changing Attitudes Reflect Falling Stigma

The good news is that cannabis stigma appears to be decreasing. I have seen attitudes change over time.

This is reflected by a shift in the types of calls I’ve received from parents seeking guidance about their kids who are using cannabis. Before 2018, the year medical cannabis became available in Pennsylvania, many of the parents who called me were terrified, their fears often based on the “gateway drug” myth.

Today, although parents coming to me are still very worried, their fears are tempered by some awareness that not only can teen cannabis use be a manageable issue, but that in some cases, cannabis seems to help their teens in ways that they couldn’t accept a few years ago.

As legalization spreads and cannabis use becomes more open, parents are less likely to be distraught and more likely to empathize.

Even so, parents continue to struggle in resolving the conflict they have between what they feel is best for their kids versus the fear-based, drug-war and rehab-industry narratives instilled in them for decades.

As legalization spreads and cannabis use becomes more open, however, parents are less likely to be distraught and more likely to empathize. They are more open to wanting to understand the reasons for their teen’s use, and to reflecting on their own cannabis-use experiences as teens.

As stigma decreases, greater numbers of people will be able to use cannabis in ways that make their lives healthier and better. It’s time to dispel myths and let the facts speak for themselves: While cannabis can have harms and is not for everyone, it’s a plant that humans have been safely consuming for over 5,000 years. Science-based information and compassion empower people, and cannabis can make game-changing contributions to human wellbeing.

*Name has been changed to protect source’s privacy. 

The post Cannabis Stigma Still Alive and Kicking, My Practice Shows appeared first on Filter.

“I was scared and alone,” Alice recalled, “pressured into admitting to drug use that never happened, unable to talk to my parents for the first week and surrounded by adolescents much older and more experienced than I.”

Alice was required to attend 12-step meetings at the facility, and made “to identify with the label of ‘addict,’” as she put it. This was despite the fact that she had not developed a substance use disorder.

What she didn’t know then was “how much their assessment of me would follow me home and impact the rest of my life.” 

“I thought that the only way to get out was to tell them what they seemed to want to hear,” she said. “When I did try to tell the truth, I was told that I was a liar and a manipulator.”

At the time, Alice believed that once she got out of rehab, it would all be over. What she didn’t know then was “how much their assessment of me would follow me home and impact the rest of my life.” 

“Despite knowing that I didn’t belong there initially, with everyone around me telling me otherwise and no one believing me, I felt trapped in that identity,” she explained, “and eventually began to doubt my own reality.” 

Taught that she was “ill,” Alice came to believe it. “I couldn’t trust my own thoughts, emotions or experiences.” 

And in her case, she said, “the treatment itself became a self-fulfilling … prophecy, as I did go on later in my adolescence to develop a problem with substances, partly to find some relief from the feelings of worthlessness and lack of control over my own life, and partly to feel I wasn’t living a lie.”

The experience also damaged the trust between her and her parents, and “set me up for additional traumatic treatment experiences in my adolescence and normalized unhealthy relationships in my adulthood.” 

“I continue to live with the impacts of the trauma from this experience to this day,” she concluded.

Alice’s story illustrates how traditional treatment can pathologize normal behaviors of adolescence, thereby reinforcing stigma and existing low self-esteem. She’s only one of countless adolescents who have been traumatized by the traditional treatment industry as a result of the medicalizing and pathologizing that is standard in one-size-fits-all programs. 

Telling teenagers they have a disease can prey on their existing emotional vulnerabilities, undermining their agency and hampering whatever motivation they may have.

The majority of substance use disorder treatment programs—ranging from outpatient, to intensive outpatient and residential/inpatient—are still 12-step based, and conduct therapy on the premise that the patient has a disease.

Teenagers usually come to treatment very reluctantly. Telling them they have a disease can prey on their existing emotional vulnerabilities, undermining their agency and hampering whatever motivation they may have to make changes. Alice’s framing of her diagnosis as “self-fulfilling” is notable; a well known study led by William Miller found “two client factors as optimally predictive of resumed drinking: lack of coping skills and belief in the disease model of alcoholism.”

Risk-taking, challenging authority and novelty-seeking are normal teen behaviors that are often part of a process of establishing autonomy and identity. Irrational behaviors, poor judgment, emotional dysregulation and problems with impulse control may be part of this. And experimentation with drugs—sometimes including unwise or excessive use, but in the context that the large majority of drug use does not lead to addiction problems—is normal.  

Labels like “alcoholic” and “addict” obscure this process. Most importantly, they erase the uniqueness of each teen and their specific family dynamics.

A related problem is treatment programs’ reliance on substance use disorder diagnoses as the foundation of their interventions. While diagnoses in general can guide treatment recommendations and serve as helpful shorthand among providers sharing information about clients, these diagnoses tend to lead to an emphasis on substance use as the treatment focus. 

This makes it less likely to address common co-occurring mental health issues such as anxiety, depression and ADHD. Treating substance use without offering strategies for addressing the mental health variables is often a recipe for disaster with teens.

Unlike Alice, Sara said that she “definitely had a problem with alcohol” by the time she went to rehab as a teenager.

“I had always suffered from anxiety,” she explained, “and the pressure of going to an Ivy League school combined with wanting to convince my parents that I was the perfect girl … drove me to medicate with alcohol.”

“When I ended up passing out at a party and going to the ER, my parents, understandably, freaked out,” she continued. Their friends and doctors urged that Sara should be sent to rehab in Pennsylvania, so her parents paid out-of-pocket for a facility that didn’t take insurance.

”I wasn’t coerced,” Sara said, “but I was absolutely terrified and had no idea what I was getting into.”

She found herself in multiple 12-step meetings every day—meetings that included men, despite her request for a women-only space because of resurfacing trauma from when she had been sexually assaulted in high school.

“After rehab, I felt like I was nothing but an ‘alcoholic,’ and doomed to fail no matter what I did.”

“I was forced to write my ‘First Step Prep’: a long story of everything bad that had happened to me on account of my drinking,” Sara related. “I had really only started drinking in college and I was a sophomore at the time, so my list wasn’t very long. When my counselor read it, she said there had to be more, so I made things up to put on the list.”

It got much worse for Sara. “When I told my therapy group about the sexual assault, they said it happened because I was an ‘alcoholic’—even though I hadn’t been drinking heavily at all until college.”

Sara left the rehab with an “aftercare plan” that involved her going to 90 12-step meetings in 90 days. This requirement separated her from her college friends, she said, and made it hard to focus on her work. But more broadly, “I felt damaged, different and flawed. Before then, my entire life, I had worked hard and felt successful. After rehab, I felt like I was nothing but an ‘alcoholic,’ and doomed to fail no matter what I did.”

Sara remained abstinent from alcohol for about eight months. But after that, she began what she called a cycle of not drinking, followed by “serious binges.” 

“I had never had such serious binges before I went to rehab,” she said, “but they convinced me that once I started, I couldn’t stop.”

Eventually, Sara ended her involvement with Alcoholics Anonymous and anything related to her past treatment. “I found a therapist who does not believe in the disease model and isn’t even a ‘substance abuse’ counselor,” she said, “and she helped me see that I am not a label and not damaged. I no longer identify as an ‘alcoholic.’”

Sara chooses not to drink these days, “but that’s because it makes my anxiety worse, not because I think I can’t stop. When I hear friends talking about having problems with alcohol or other drugs, I tell them whatever you do, do not go to rehab!”

Unfortunately, like Sara’s family, many people think that when a teenager (or anyone) is showing signs of problems with substances, traditional rehab is the answer. The result is that many teens emerge feeling stigmatized, different from their peers or, like Sara, damaged.

Again, most drug use is not problematic. And people use drugs for reasons. All humans experience compulsive behaviors to some degree, related to an underlying psychological process involving an interaction of emotional factors unique to each person. People who experience compulsive, damaging relationships with drugs that they wish to change can certainly benefit from the right kinds of help. But stigmatizing drug use is never the right approach.

Instead, we need a treatment model that reflects a young person’s unfolding developmental trajectory, offering holistic and flexible options based on the person’s wishes, rather than the static disease approach.

I know this from long experience. After 30 years as a psychologist practicing under the traditional model, I felt burnt out as I saw my clients not just returning to substance use, but overdosing and dying. Feeling helpless, I almost left the field—and then I was led to discover harm reduction treatment approaches.

People find a harm reduction treatment approach empowering and motivating as they develop strategies to move towards well-being.  

Treatment from this perspective focuses on collaboratively helping teens understand their urges to get high, anticipate and better manage impulses to use, and work through any underlying issues that are being temporarily solved by getting high. 

I have found that teenagers are far more open to collaborating in treatment that doesn’t reinforce shortcomings and failures, and when they feel invested in the process of change. 

In this treatment environment, we nonjudgmentally frame drug use as a choice—one that a person can have control over—and foster discussions of different options for coping, both with urges to use and with life.

Today, in working with teenagers and their families, I meet people where they’re at, listen to what they want, collaborate with them to increase engagement, and educate families with science-based information. People find this approach empowering and motivating as they develop strategies to move towards well-being.  

When such a model exists, it is long overdue that experiences like those endured by Alice and Sara be consigned to the past.

*Names have been changed to protect sources’ privacy.

Photograph via RawPixel/Public Domain

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